Green tea may delay onset of type 1 diabetes

Drs. Stephen Hsu and Kevin Gillespie.
AUGUSTA, Ga., 26 oct 2008 – A powerful antioxidant in green tea may prevent or delay the onset of type 1 diabetes, Medical College of Georgia researchers say.
Researchers were testing EGCG, green tea's predominant antioxidant, in a laboratory mouse with type 1 diabetes and primary Sjogren's syndrome, which damages moisture-producing glands, causing dry mouth and eyes.
"Our study focused on Sjogren's syndrome, so learning that EGCG also can prevent and delay insulin-dependent type 1 diabetes was a big surprise," says Dr. Stephen Hsu, molecular/cell biologist in the School of Dentistry.
They found it also worked well in their original disease focus.
In the mouse, EGCG reduced the severity and delayed onset of salivary gland damage associated with Sjogren's syndrome, which has no known cure.
"EGCG modulates several important genes, so it suppresses the abnormality at the molecular level in the salivary gland. It also significantly lowered the serum autoantibodies, reducing the severity of Sjogren's syndrome-like symptoms," Dr. Hsu says. Autoantibodies are antibodies the body makes against itself.
Both type 1 diabetes and Sjogren's syndrome are autoimmune diseases, which cause the body to attack itself. Autoimmune disorders are the third most common group of diseases in the United States and affect about 8 percent of the population, says Dr. Hsu. Sjogren's syndrome can occur alone or secondary to another autoimmune disease, such as lupus, rheumatoid arthritis or type 1 diabetes.
The study, published in the Oct. 24 issue of Life Sciences, supports earlier research showing EGCG's impact on helping prevent autoimmune disease.
Researchers treated a control group of mice with water and a test group with a purified form of EGCG dissolved in the drinking water. At 16 weeks, the EGCG-fed mice were 6.1 times more likely to be diabetes-free than the water-fed group, and 4.2 times more likely at 22 weeks.
"Previous studies used another animal model that developed type 1 diabetes only after an injected chemical killed the insulin-producing cells. That may not accurately resemble disease development in humans, because type 1 diabetes is a genetic disease," says Dr. Hsu, the study's corresponding author.
"Our study is significant because we used a mouse model with the genetic defects that cause symptoms similar to human type 1 diabetes and Sjogren's syndrome, so the immune cells attack the pancreas and salivary glands until they are no longer functional."
Another related finding was that even when salivary cells were under attack, they seemed to be rapidly reproducing in the control group. The proliferation was suppressed in the EGCG-fed group.
"It's kind of counterintuitive – why would there be proliferation of the glandular cells occurring when the present cells are not secreting saliva?" says Dr. Kevin Gillespie, first author of the study he conducted for his master's research project at MCG.
The proliferation phenomenon also can be observed in psoriasis, an autoimmune disease affecting the skin and joints, says Dr. Hsu. "Normal skin cells turn over every 30 days or so, but skin cells with psoriasis turn over every two or three days." Dr. Hsu's group previously found that green tea polyphenols, including EGCG, inhibited rapid proliferation in an animal model for human psoriasis.
"We never thought proliferation was going on to this extent in the salivary gland, but we now believe it is tightly associated with Sjogren's syndrome," he says.
The next step is to observe Sjogren's syndrome in human salivary gland samples to determine whether the study findings hold up in humans.
"If the abnormal expression of these genes is the same in humans as in the animal model, then the second stage will be intervention and treatment with a pure form of EGCG," says Dr. Hsu.
"The benefit of using green tea in preventing or slowing these autoimmune diseases is that it's natural and not known to harm the body," says Dr. Gillespie, periodontics chief resident at Fort Gordon's Tingay Dental Clinic. "EGCG doesn't have the negative side-effects that can be associated with steroids or other medications that could otherwise be prescribed."

Even mild sleep apnea increases cardiovascular risk

26 oct 2008--People with even minimally symptomatic obstructive sleep apnea (OSA) may be at increased risk for cardiovascular disease because of impaired endothelial function and increased arterial stiffness, according to a study from the Oxford Centre for Respiratory Medicine in the UK.
"It was previously known that people with OSA severe enough to affect their daytime alertness and manifest in other ways are at increased risk of cardiovascular disease, but this finding suggests that many more people—some of whom may be completely unaware that they even have OSA—are at risk than previously thought," said lead author of the study, Malcolm Kohler, M.D.
The study will be published in the first issue for November of the American Thoracic Society's American Journal of Respiratory and Critical Care Medicine.
"Only one out of approximately five subjects with [clinically defined OSA] complains of excessive daytime sleepiness in population studies," wrote Geraldo Lorenzi-Filho, M.D., Ph.D. in an editorial in the same issue of the Journal. "[I]t is now recognized that OSA triggers a cascade of biological reactions, including increased sympathetic activity, systemic inflammation, oxidative stress, and metabolic alterations that are potentially harmful to the cardiovascular system."
To determine the exact nature of some of these effects, Dr. Kohler and colleagues performed a controlled, cross-sectional study to assess differences in endothelial function (often a harbinger for cardiovascular problems to come), arterial stiffness and blood pressure in patients with minimally symptomatic OSA. They compared 64 patients who had proven OSA to matched control subjects without OSA.
Their findings suggested that minimally symptomatic OSA is a cardiovascular risk factor to a degree not previously known.
"In our study, the augmentation index, a measure of central arterial stiffness that independently predicts cardiovascular events in high-risk populations, was significantly higher in patients with minimally symptomatic OSA compared to matched controls," said Dr. Kohler. "We also found impaired endothelial function as indicated by decreased vascular reactivity of their arteries compared to control subjects without OSA."
The difference in arterial stiffness between OSA patients and control subjects, Dr. Kohler said was "comparable in size to the effect seen after four weeks' continuous positive airway pressure (CPAP) therapy in patients with moderate to severe symptomatic OSA."
This suggests that asymptomatic or minimally symptomatic patients with OSA may enjoy a cardiovascular benefit from CPAP therapy.
Dr.Kohler and colleagues from the Oxford Centre for Respiratory Medicine are currently investigating the effects of 6 month CPAP therapy on arterial stiffness and endothelial function as part of an international randomized controlled trial (Multicentre Obstructive Sleep Apnoea Interventional Cardiovascular Trial; MOSAIC) which will show the impact of CPAP therapy on cardiovascular risk in patients with minimally symptomatic OSA.
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Full Text of Original Article Available Here: http://www.thoracic.org/sections/publications/press-releases/resources/110108Kohler.pdf
Full Text of Original Editorial Available Here: http://www.thoracic.org/sections/publications/press-releases/resources/OSAed110108.pdf

Half of Doctors Routinely Prescribe Placebos

By GARDINER HARRIS
25 oct 2008--Half of all American doctors responding to a nationwide survey say they regularly prescribe placebos to patients. The results trouble medical ethicists, who say more research is needed to determine whether doctors must deceive patients in order for placebos to work.
The study involved 679 internists and rheumatologists chosen randomly from a national list of such doctors. In response to three questions included as part of the larger survey, about half reported recommending placebos regularly. Surveys in Denmark, Israel, Britain, Sweden and New Zealand have found similar results.
The most common placebos the American doctors reported using were headache pills and vitamins, but a significant number also reported prescribing antibiotics and sedatives. Although these drugs, contrary to the usual definition of placebos, are not inert, doctors reported using them for their effect on patients’ psyches, not their bodies.
In most cases, doctors who recommended placebos described them to patients as “a medicine not typically used for your condition but might benefit you,” the survey found. Only 5 percent described the treatment to patients as “a placebo.”
The study is being published in BMJ, formerly The British Medical Journal. One of the authors, Franklin G. Miller, was among the medical ethicists who said they were troubled by the results.
“This is the doctor-patient relationship, and our expectations about being truthful about what’s going on and about getting informed consent should give us pause about deception,” said Dr. Miller, director of the research ethics program in the department of bioethics at the National Institutes of Health.
Dr. William Schreiber, an internist in Louisville, Ky., at first said in an interview that he did not believe the survey’s results, because, he said, few doctors he knows routinely prescribe placebos.
But when asked how he treated fibromyalgia or other conditions that many doctors suspect are largely psychosomatic, Dr. Schreiber changed his mind. “The problem is that most of those people are very difficult patients, and it’s a whole lot easier to give them something like a big dose of Aleve,” he said. “Is that a placebo treatment? Depending on how you define it, I guess it is.”
But antibiotics and sedatives are not placebos, he said.
The American Medical Association discourages the use of placebos by doctors when represented as helpful.
“In the clinical setting, the use of a placebo without the patient’s knowledge may undermine trust, compromise the patient-physician relationship and result in medical harm to the patient,” the group’s policy states.
Controlled clinical trials have hinted that placebos may have powerful effects. Some 30 percent to 40 percent of depressed patients who are given placebos get better, a treatment effect that antidepressants barely top. Placebos have also proved effective against hypertension and pain.
But despite much attention given to the power of placebos, basic questions about them remain unanswered: Are they any better than no treatment at all? Must people be deceived into believing that a treatment is active for a placebo to work?
Some studies have hinted at answers, but experts say far more work is needed.
Dr. Howard Brody, director of the Institute for the Medical Humanities at the University of Texas Medical Branch, in Galveston, said the popularity of alternative medical treatments had led many doctors to embrace placebos as a potentially useful tool. But, Dr. Brody said, doctors should resist using placebos, because they reinforce the deleterious notion that “when something is the matter with you, you will not get better unless you swallow pills.”
Earlier this year, a Maryland mother announced that she would start selling dextrose tablets as a children’s placebo called Obecalp, for “placebo” spelled backward.
Dr. Ezekiel J. Emanuel, one of the study’s authors, said doctors should not prescribe antibiotics or sedatives as placebos, given those drugs’ risks. Use of less active placebos is understandable, he said, since risks are low.
“Everyone comes out happy: the doctor is happy, the patient is happy,” said Dr. Emanuel, chairman of the bioethics department at the health institutes. “But ethical challenges remain.”

Obesity pill shows promise: study

By Michael Kahn
LONDON, 25 oct 2008– People taking NeuroSearch A/S's obesity pill tesofensine lost twice as much weight as men and women using approved weight loss drugs, Danish researchers said on Thursday.
The study suggest the experimental drug is safe because it had no effect on blood pressure and only raised heart rate slightly, said Arne Astrup of the University of Copenhagen, who led the study published in the journal Lancet.
"It is quite solid from this study that it seems to produce a weight loss that is twice ... what we see from existing compounds on the market," Astrup said in a telephone interview.
The company hopes to take tesofensine to Phase III clinical trials early next year -- the last stage of human testing before a company can seek regulatory approval for a drug.
Obesity, which raises the risk of diseases like type 2 diabetes and heart problems, is increasingly a problem as more people adopt a Western lifestyle.
The World Health Organization classifies around 400 million people around the world as obese, representing an increasingly lucrative market for drug makers.
Astrup and his team compared tesofensine against the Sanofi-Aventis SA obesity-fighting drug Acomplia and Abbott Laboratories' Reductil, known as Meridia in the United States.
The 203 obese volunteers at five Danish obesity centers were given different doses of tesofensine or placebo. The drug worked twice as well as previously published data on Acomplia and Reductil, known generically as sibutramine, the study showed.
SIDE EFFECTS
After the study ended, the men and women on tesofensine had lost 10 kilograms more than people on placebo, compared with studies which have shown weight loss of 3 kilograms for Reductil and about 5 kilograms for Acomplia over a similar six month period, Astrup said.
Side effects included dry mouth, constipation and insomnia, but importantly the volunteers did not exhibit the suicidal thoughts that have plagued Acomplia, known generically as rimonabant, Astrup said.
Acomplia took a hit last year when a U.S. expert panel recommended against its approval in the world's biggest market after it was linked to rare cases of suicide ideation -- a psychological problem not shown to raise the risk of suicide but one that worries doctors.
"So far there have been no warnings about problematic side effects," Astrup said. "It seems clean so far."
Other researchers not involved in the study cautioned that the results are from a single trial in a relatively small number of patients.
"We should therefore be a little circumspect about accepting these claims as to efficacy and await the results of the more relevant Phase III studies, which the author does say at the end of the paper," Ian Broom, a researcher at Robert Gordon University in Britain said in a statement.
Tesofensine works by interfering with three brain chemicals -- noradrenline, serotonin and dopamine -- involved in regulating hunger. People who take the pill are less hungry and feel full more quickly.
The next step are Phase III trials in which doctors will also try to regulate diet, something that Astrup said could lead to the kind of weight loss associated with gastric-bypass surgery.
"Most clinicians are always saying we need more effective drugs that can make surgery not necessary," Astrup said. "This is the first opening we have seen."

Stories in the Service of Making a Better Doctor

By PAULINE W. CHEN, M.D.
25 oct 2008--The white-coated crowd with stethoscopes slung casually around their necks would have looked familiar to anyone who has attended morning hospital rounds. Resident physicians and medical students milled about, chatting animatedly, and at the appointed hour, the attending physician signaled to begin.
But instead of filing toward a patient’s room, the group at Saint Barnabas Medical Center in Livingston, N.J., settled into a conference room at the end of the hall, not to recite details of patient cases but to read “Empty Pockets,” a personal essay by Dr. Kevan Pickrel from The Annals of Internal Medicine. In the piece, Dr. Pickrel describes being unable to save a 36-year-old woman, then going to the waiting room to inform the woman’s family of her death:
“The youngest daughter sat on Dad’s lap looking at pictures in an outdoors magazine. The older sat watching her hands rest in her lap. [The] husband’s eyes lifted to me and met mine. I didn’t, couldn’t, say a word.... He turned back toward his daughters, a single father, and they lifted their eyes to his. As he drew a breath to begin, his eldest daughter knew.”
After the reading, the attending physician, Dr. Sunil Sapra, looked up at the group assembled. “Do you identify with any of these situations?” he asked.
“Yes, it happens all the time,” a resident responded immediately. Others nodded in agreement, and one resident flicked a tear away.
The next morning, in a similar room at New York-Presbyterian Hospital in upper Manhattan, a group of obstetrics and gynecology residents gathered to read E.B. White’s short story “The Second Tree From the Corner.” Told from the perspective of an anxiety-ridden patient, the story ends with the main character finding meaning in his life and suddenly feeling liberated:
“He felt content to be sick, unembarrassed at being afraid; and in the jungle of his fear he glimpsed (as he had so often glimpsed them before) the flashy tail feathers of the bird courage.”
As the reading ended, one of the young doctors commented on how personally fulfilling it was to help her patients and how those feelings invigorated her, even after many hours of work. Other doctors in the room nodded in agreement.
While it has long been understood that clinical practice influenced the youthful writing of doctor-authors like Chekhov and William Carlos Williams, there is now emerging evidence that exposure to literature and writing during residency training can influence how young doctors approach their clinical work. By bringing short stories, poems and essays into hospital wards and medical schools, educators hope to encourage fresh thinking and help break down the wall between doctors and patients.
“We’re teaching the humanities to our residents, and it’s making them better doctors,” said Dr. Richard Panush, a rheumatologist and chairman of the department of medicine at Saint Barnabas.
The idea of combining literature and medicine — or narrative medicine as it is sometimes called — has played a part in medical education for over 40 years. Studies have repeatedly shown that such literary training can strengthen and support the compassionate instincts of doctors.
Dr. Rita Charon and her colleagues at the program in narrative medicine at Columbia University’s College of Physicians and Surgeons found, for example, that narrative medicine training offered doctors opportunities to practice skills in empathy. Doctors exposed to literary works were more willing to adopt another person’s perspective, even after as few as three or four one-hour workshops.
“You want people to be able to leave their own individual place,” Dr. Charon said, “and ask what this might be like for the child dying of leukemia, the mother of that child, the family, the hospital roommate.”
Over the last 15 years, an ever-increasing number of medical schools have begun offering narrative medicine to medical students. These courses often involve writing, reading and discussing works by authors as diverse as Leo Tolstoy, Virginia Woolf, Lori Moore and various doctor-authors. Students then explore the relevance of these texts, and their own writing, to their clinical work.
But until recently, few educators have attempted to bring such literary training into residency programs.
Residency is the most intense period of a young doctor’s life. The years spent squirreled away in hospitals and clinics are rich in clinical learning, but the wealth of that experience comes at the cost of free time.
And with time at a premium, residency program directors and clinical educators have been hesitant to add narrative medicine to their curricula, particularly since it has never been clear that such an addition would have any effect other than further overworking the trainees.
That could be changing.
For over a year now, Dr. Panush, a tall, bespectacled, soft-spoken man with the lean physique of a runner, has been systematically incorporating literature into the daily rounds of every one of the internal medicine residents at Saint Barnabas Medical Center.
As part of the Accreditation Council for Graduate Medical Education’s Education Innovations Project, Dr. Panush and his faculty colleagues bring poetry, short stories and essays to rounds each day and discuss them in the context of the patients they see. These daily discussions, supplemented by offsite weekly conferences, form the core of the residents’ narrative medicine experience.
One year into the program, Dr. Panush and his colleagues looked at the effect of these daily discussions on the residents and their patients. What they found were significant improvements in patient evaluations of residents and patients’ health and quality of life, from hospital admission to discharge.
A handful of other residency programs across the country have taken steps toward establishing narrative medicine training for their residents, including Vanderbilt University’s Department of Surgery and New York/Presbyterian Hospital-Columbia’s Department of Obstetrics and Gynecology. As with the program at Saint Barnabas, it has been the doctors within these departments who have initiated the workshops, sessions and lectures.
“As we improve the technology of medicine, we also need to remember the patient’s story,” said Dr. A. Scott Pearson, an associate professor of surgery at Vanderbilt University Medical Center.
To that end, Dr. Pearson has completed a pilot study examining the feasibility of incorporating narrative medicine into Vanderbilt’s surgical residency and has plans to make such training available eventually to all surgical residents at his medical center. Dr. Pearson believes that narrative medicine will not only help residents reflect on what they are doing and how they might do better, but may also aid surgical educators in teaching professionalism and communication skills.
“Narrative medicine changed my entire approach to medicine,” said Dr. Abigail Ford, a senior resident in obstetrics and gynecology at New York-Presbyterian Hospital/Columbia who studied under Dr. Charon as a medical student. “As a doctor you are really a co-author of patients’ experiences and need to hear their story and take it on.”
With her former professor’s guidance, as well as the support of Dr. Rini Ratan, the residency program director, Dr. Ford has initiated a narrative medicine program for her fellow obstetrics and gynecology residents. While the program is still in its first year, “we’ve always run over,” said Dr. Ford. “People have to be dragged away.”
“Our hope is to look at it in terms of physician empathy,” added Dr. Ratan, “Does it add anything? Does it prevent natural jadedness over the course of the busy training process? Does it prevent burnout?”
In the near future, Dr. Ratan and Dr. Ford also hope to begin doing the kind of patient outcome evaluations that Dr. Panush and his colleagues have begun.
“To do what we’re doing is pretty simple,” said Dr. Panush. “But the measurement stuff is harder. The program needs to be supported institutionally and internally.”
Despite such challenges, the effects of these programs are striking. Dr. Benjamin Kaplan, a second-year resident at Saint Barnabas, remarked on the transformation he saw in fellow resident physicians during the first year of the humanities program.
“Their management of patients changed,” Dr. Kaplan said. “They remembered to do things that I don’t think they would have otherwise done, like always talking to the family, gently touching patients, and continually explaining the course of treatment and what the doctors are thinking so patients know.”
And the time commitment? “It does get pretty busy,” Dr. Kaplan conceded. “But if you want to make time for it, you can. Spending a half hour a day to remember that we are all human, not just doctors or pharmacists or nurses or patients, is important enough that I think you should do it.”
Although it is still too early to determine the long-term effects of narrative medicine on doctors in training, residents were quick to note that certain essays, short stories and poems they have read on rounds continue to influence their work.
Dr. Ramesh Guthikonda, a second-year resident at Saint Barnabas, spoke about a poem called “When You Come Into My Room,” by Stephen A. Schmidt. In the poem, published in The Journal of the American Medical Association, a man struggling with chronic illness lists all that he believes a doctor meeting him should know:
“When you come into my hospital room, you need to know the facts of my life
that there is information not contained in my hospital chart
that I am 40 years married, with four children and four grandchildren....
that I love earthy sensuous life, beauty, travel, eating, drinking J&B scotch, the theater, opera, the Chicago Symphony, movies, all kinds, water skiing, tennis, running, walking, camping...
that I am chronically ill, and am seeking healing, not cure.”
The poem so affected Dr. Guthikonda that he began regularly asking his patients about their hobbies and families, and he enrolled in a Spanish class so he could learn to better pronounce their names. “My rapport with patients, especially with my Hispanic patients, was not up to the mark,” he said. “I never asked about the patients’ lives, about who they are. I am much more sensitive to those issues now.”
Reflecting on the changes in Dr. Guthikonda, Dr. Panush said, “We changed the way he thinks and does medicine. You can’t put a p-value on that.”

Weight-Loss Surgery, No Cutting Required

By DENISE GRADY
25 oct 2008--A Patient's ProgressThis is the first in a series of articles that will periodically chronicle Karleen Perez’s efforts to lose weight.
On a recent Wednesday, Karleen Perez lay unconscious on an operating table in Upper Manhattan while her surgeons and two consultants from a medical device company peered at an overhead monitor that displayed images from inside her digestive tract.
The surgeons, Dr. Marc Bessler and Dr. Daniel Davis, had just stapled her stomach to form a thumb-sized tube that would hold only a small amount of food. The operation resembled others done for weight loss, with one huge difference. In Ms. Perez’s case, there was no cutting. Instead, the surgeons had passed the stapler down her throat and stapled her stomach from the inside.
Inspecting their handiwork, Dr. Bessler said, “I don’t think you’ll get much better than that.”
The operation, meant to make people feel full after eating very little, is strictly experimental. Only a few patients have tried it in this country, as part of a study paid for by Satiety Inc., which makes the staplers and hopes the Food and Drug Administration will approve them.
Ms. Perez, a 25-year-old graduate student in social work, was the second patient at NewYork-Presbyterian Hospital/Columbia to enter the study. Satiety employees advised her surgeons throughout the operation.
The procedure is part of a trend to make surgery less painful and invasive, to minimize risks and speed recovery. Many operations that once required big incisions are now performed through small slits, with cameras inserted to let surgeons see what they are doing on video screens. Ms. Perez’s doctors took the next step: using a natural opening to avoid cutting through the abdominal wall. Dr. Bessler and other surgeons have used similar techniques to remove the appendix through the mouth, and the gallbladder through the vagina.
In Mexico and Europe over the past two to three years, 98 patients have had the new weight-loss surgery, named Toga (for transoral gastroplasty). On average, those who have passed the one-year mark have lost about 40 percent of their excess weight. Only time will tell whether they will be able to avoid gaining it back.
There are older, well-established operations that produce more weight loss, and in the United States 200,000 people have them each year. Known as bariatric surgery, it is often done through slits.
But even the slits leave scars and slice through abdominal muscles, which causes pain, Dr. Bessler said. The operations can have complications, too, like hernias and leaks in the digestive tract.
“Most people don’t want the risk,” he said, adding that only about 2 percent of those who might be helped by bariatric surgery actually have it.
About 15 million Americans are morbidly obese, meaning their body mass index — a type of weight/height ratio — is at least 40 (overweight begins at 25). Medical guidelines recommend surgery when the index reaches 40, or 35 if there are also complications like diabetes or heart disease.
Ms. Perez is 5-foot-9 and weighs 289 pounds, for a body mass index of 42 — though her height and generous frame help hide the weight. Her family, friends and boyfriend say she looks just fine.
But she has mixed feelings about her appearance. She weighed 175 or 180 pounds in high school and was comfortable with that weight. But she gained 90 pounds in college and could not take it off. She hopes the operation will help her lose 60 pounds, maybe even in time for her graduation this coming spring from Stony Brook University.
“I don’t feel like it’s a big issue, but of course it is,” she said. “If I go out with my sorority sisters or friends to buy clothes, I probably can’t buy where they do. I’m the one who comes out with accessories. That’s a bummer.”
More important, she said, is her health. She becomes winded too easily, and her blood pressure “is not great,” she said, adding, “I just want to live healthy and not be borderline anything.”
Bariatric operations typically work far better than diet, exercise or drugs, and they often cure diabetes and reduce the risk of dying from heart disease or cancer. But there is also a risk — albeit small, less than 1 percent at experienced centers — of dying from the surgery itself.
The idea behind Toga is to offer something safer and less invasive. Dr. Bessler said he thought it would appeal to many people who feared the other operations.
“It has a lot of promise,” he said. “I deal with a lot of new technologies. This, I’m really excited about.” Dr. Bessler said that he and Dr. Davis had no financial interest in Satiety but that the company did pay for their work on the study.
Other companies are also developing new devices and minimally invasive operations to cash in on America’s booming obesity epidemic, but Satiety is among the first to start testing its products in people.
A surgeon not involved in the Toga study, Dr. Philip Schauer, director of bariatric surgery at the Cleveland Clinic, called the new operation very promising and said that so far it seemed to offer “a drastic reduction in side effects and risk.”
Though she wanted surgery, Ms. Perez did not want a gastric bypass, the most common bariatric operation, which shrinks the stomach and rearranges the small intestine. Her aunt had it and lost 150 pounds, but suffered from a hernia, intestinal problems and other serious complications.
So Ms. Perez considered gastric banding, a less extreme and increasingly popular operation that inserts a loop around the top of the stomach and tightens it to form a small pouch.
But Toga, which she discovered on the Internet, seemed less invasive. Also, the price was right: the operation would be free as part of the study. She did not mind if it produced less weight loss than the other methods.
“To me, it’s not about being completely skinny,” she said. “I’m told I could lose 40 percent of my excess weight.”
If she exercises and diets after the operation, she said, “I’ll probably lose, like, 60 pounds, and that’s realistic to me.”
Temporarily, she kept her plans a secret from most of her friends and impishly told some that she was having her tonsils out. She took down her Facebook page and put a note in MySpace saying that there would be some changes made.
The operation is not as simple as it might sound. To begin, Ms. Perez was given general anesthesia and put on a respirator. Then the surgeons pushed a dilator, a formidable-looking tube about three-quarters of an inch wide, down her throat to stretch her esophagus.
Next came another wide tube, this one about two feet long, containing the stapler. The surgeons inflated her stomach with carbon dioxide to create space in which to work. Dr. Bessler struggled for 5 or 10 minutes to position the stapler properly, and then activated controls that opened it, like a miniature spaceship, inside Ms. Perez’s stomach.
A sail and curving wire emerged from the stapler to help push aside the folds of her stomach. Then Dr. Bessler turned on a vacuum pump to draw parts of the front and back walls of the stomach into the device to be stapled together.
Three rows of staples were needed, but the stapler holds only one row, so the whole apparatus had to be withdrawn, rinsed, reloaded, pushed back down Ms. Perez’s throat and painstakingly repositioned for each row. The Satiety consultants stood close by to coach, at one point warning Dr. Bessler that if he inflated Ms. Perez’s stomach too much, her first row of staples could pop. The surgery took three hours.
“Every operation has its learning curve,” Dr. Bessler said. “We saw a doctor in Brussels who took an hour and a half, but he had done 70.”
The next morning at the hospital, Ms. Perez was in good spirits despite a horrendous sore throat from the operation. She said she had awakened during the night wondering what she had done, and had thought, “This is going to be super life-changing.”
She would be on a liquid diet for several weeks. A nutritionist had given her a pamphlet that commanded, “Don’t Stretch Your Stomach!,” warned that eating too much or too fast could cause vomiting, and advised that the best time to lose weight would be in the next 6 to 12 months, because the body would try to fight the surgery by absorbing more nutrients.
She thought she could do it. She would start slowly, by taking longer and longer walks. She hoped to join a gym, start running, eventually finish a marathon. She wanted to look cool for her graduation.
“My friends are going to be shocked,” she said. “Through struggle comes success.”

Sanofi-Aventis withdraws anti-obesity drug from sale in Europe

PARIS.24 oct 2008 – EU authorities suspended sales of pharmaceutical giant Sanofi-Aventis' anti-obesity drug Acomplia across the continent Thursday, the firm announced, adding that it had not ruled out a worldwide halt.
"Sales have been halted in all the pharmacies in the 18 countries of the European Union where it is distributed," a company spokesman told AFP.
Sanofi-Aventis said the European Medicines Agency (EMEA) had warned that patients taking the drug ran almost double the normal risk of psychiatric problems.
"The risks of taking Acomplia are now greater than the benefits that the drug can bring the patient according to its current guidelines," the company said, citing the EMEA.
Europe has allowed sales of Acomplia since 2006, but it has not been authorised in the United States where authorities believe it encourages suicidal thoughts, even in patients with no history of depression.
The company said it had not ruled out withdrawing the drug in the 14 non-EU countries where it is sold. It said users of the drug should consult a doctor or pharmacist.

Speedy eaters seen likelier to get fat

LONDON, 24 oct 2008– People who eat quickly until full are three times more likely to be overweight, a problem exacerbated by the availability of fast food and the decline of orderly dining habits, Japanese researchers said on Wednesday.
The findings, published in the British Medical Journal, highlight how eating styles, and not just what or how much is eaten, can contribute to an obesity epidemic fueled by the spread of Western-style affluence in many parts of the world.
The World Health Organization classifies around 400 million people as obese, 20 million of them under the age of five. The condition raises the risk of diseases like type 2 diabetes and heart problems.
For their study, Hiroyasu Iso and colleagues at Osaka University asked more 3,000 Japanese volunteers aged 30 to 69 about their eating. About half of the men and a little more than half of the women said they ate until full. About 45 percent of the men and 36 percent of the women said they ate quickly.
Those who said they ate until full and ate quickly were three times more likely to be fat than people in the "not eating until full and not eating quickly" group, the researchers found.
They cited as causes both the availability of cheap food in big portions and habits like watching television while eating.
To counteract the "supra-additive effect" of speedy or glut eating among children prone to obesity, parents should encourage them to eat slowly and in calm surroundings, the study found.
(Reporting by Michael Kahn; Editing by Dan Williams)

Job, Education May Buffer Against Dementia

TUESDAY, 24 oct 2008-- Having a higher level of education and a mentally demanding job may help protect against the memory loss that precedes Alzheimer's disease, according to an Italian study.
It included 242 people with Alzheimer's, 72 with mild cognitive impairment, and 144 with no memory problems. People with mild cognitive impairment have memory problems beyond what's normal for their age but not the serious memory problems associated with Alzheimer's disease.
The participants' memory and cognitive skills were tested, and their brains were scanned to look for changes and damage. They were then followed for an average of 14 months, during which time 21 of those with mild cognitive impairment developed Alzheimer's disease.
Among people with the same level of memory impairment, those with more education and more mentally demanding jobs had significantly fewer brain changes and damage than those with less education and less mentally demanding occupations.
This was true in both those with Alzheimer's and those with mild cognitive impairment who developed Alzheimer's, which suggests the cognitive reserve is already in effect during the mild cognitive impairment that precedes Alzheimer's.
"The theory is that education and demanding jobs create a buffer against the effects of dementia in the brain, or a cognitive reserve," study author Dr. Valentina Garibotto, of the San Raffaele University and Scientific Institute and the National Institute of Neuroscience in Milan, said in an American Academy of Neurology news release.
"Their brains are able to compensate for the damage and allow them to maintain functioning in spite of damage. There are two possible explanations. The brain could be made stronger through education and occupational challenges. Or, genetic factors that enabled people to achieve higher education and occupational achievement might determine the amount of brain reserve. It isn't possible to determine which accounts for our findings," Garibotto said.
The study was published in the Oct. 21 issue of Neurology.

Lumpectomy not advised if breast cancer returns


NEW YORK , 24 oct 2008– A mastectomy is prudent when breast cancer returns after a lumpectomy, because survival rates are better than with another lumpectomy, according to a new report.
"We were surprised to find that so many women in our study -- almost a quarter of them -- had received another lumpectomy rather than a mastectomy," Dr. Steven L. Chen, from the University of California Davis Cancer Center in Sacramento, said in a statement.
"It's likely," he added, "that patients are asking for lumpectomies when their cancer is diagnosed a second time, and their doctors are simply complying with that request. Whatever the reason, that decision can shorten life spans."
The study, in the American Journal of Surgery, involved 747 women who had a same-breast cancer recurrence after undergoing breast conservation therapy. Twenty-four percent of these patients underwent a second lumpectomy.
The 5-year survival rate was 67 percent for women who had a lumpectomy compared with 78 percent for those who had a mastectomy. An analysis confirmed that lumpectomy reduced the odds of survival by 50 percent.
"As therapy for breast cancer becomes more targeted and researchers come closer to identifying those factors that make some breast cancers more aggressive than others, we may have the option of recommending second, and even third lumpectomies in select cases in the future," study co-author Dr. Steven Martinez commented.
"Until then," he added, "mastectomy remains the best option for women experiencing a same-breast recurrence of their breast cancer."
SOURCE: American Journal of Surgery, October 2008.

Gastric bypass cuts heart risks

By Anthony J. Brown
NEW YORK, 24 oct 2008– The risk faced by obese people of having a heart attack or other cardiovascular "events" is reduced substantially after they undergo gastric bypass surgery to lose weight, according to a recent study.
The take-home message is that "bariatric surgery can be considered as a means to reduce cardiovascular risk (in obese patients) after conservative treatment options have failed," Dr. John A. Batsis told Reuters Health.
Batsis, at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire and his colleagues identified six studies that looked at cardiovascular risk after bariatric surgery for obesity. The risk was estimated from standard tables that assigned a score for factors such as weight, blood pressure and cholesterol levels.
Depending on how the patients' risk was assessed, the researchers found that gastric bypass reduced the risk for a future cardiovascular event anywhere from 8 percent to 79 percent, compared to not having the procedure, the team reports in the American Journal of Cardiology.
Looked at another way, the predicted chance of having a heart attack or needing heart surgery or dying of heart disease over 10 years fell from 7.0 percent to 3.5 percent after undergoing bariatric surgery. For people who did not have surgery, the probability fell from 7.1 percent to 6.5 percent.
These figures were estimates. As Batsis noted, "Further studies are required to better understand the long-term impact of bariatric surgery on predicted cardiovascular risk in obese patients by determining the actual number of cardiac events."
SOURCE: American Journal of Cardiology, October 1, 2008.

Panel Calls for Vaccine for Adult Smokers

ATLANTA, 23 oct 2008 -- For the first time, an influential government panel is recommending a vaccination specifically for smokers. The panel decided Wednesday that adult smokers under 65 should get pneumococcal vaccine. The shot -- already recommended for anyone 65 or older -- protects against bacteria that cause pneumonia, meningitis and other illnesses.
Federal officials usually adopt recommendations made by the panel, the Advisory Committee on Immunization Practices. The vote means more than 31 million adult smokers probably will soon be called on to get the shot.
Studies have shown that smokers are about four times more likely than nonsmokers to suffer pneumococcal disease. Also, the more cigarettes someone smokes each day, the higher the odds they'll develop the illnesses.
Why smokers are more susceptible is not known for sure, but some scientists believe it has to do with smoking-caused damage that allows the bacteria to more easily attach to the lungs and windpipe, said Dr. Pekka Nuorti, a medical epidemiologist with the Centers for Disease Control and Prevention.
Pneumococcal infections are considered the top killer among vaccine-preventable diseases. It's a common complication of influenza, especially in the elderly, and is considered responsible for many of the 36,000 annual deaths attributed to flu.
The committee voted 11 to 3 to pass the recommendation, with one member abstaining. The panel also added a call for smoking cessation counseling.
Some members said it might be more cost effective to recommend the vaccine for smokers who were at least age 40, because pneumococcal disease is relatively uncommon in younger smokers. Others at the meeting made the same argument.
Dr. James Turner, who oversees student health programs at the University of Virginia, said about one in five college students smoke but he has never seen a case of serious pneumococcal disease in a student body.
''I wonder how many young people are truly benefiting from this'' recommendation, said Turner, speaking as a representative of the American College Health Association.
The shot is less than perfect. First licensed in 1983, it is designed to protect against 23 strains of pneumococcal bacteria. But it hasn't proved very effective against pneumonia, and hasn't been very effective in warding off other pneumococcal illnesses in people with weakened immune systems and people age 80 or older.
It's to be given to smokers as a one-time dose with no booster, but its protection drops off after five to 10 years.
Made by Merck & Co., it's sold under the trade name Pneumovax and costs about $30 a dose.
A different vaccine -- Wyeth's Prevnar, which came on the market in 2000 -- is recommended for children under age 2, and for kids 2 to 5 with certain chronic conditions or who are at higher risk for illness.
Prevnar protects against seven strains of bacteria that were the most common causes of pneumococcal diseases at the time the vaccine was developed. But lately, those strains have stopped being important causes of illness. Experts have become concerned about dozens of other strains, including some that have flourished and become resistant to antibiotics.
Wyeth has been developing a new vaccine. It is expected to present study data on it at a scientific meeting later this month, and to apply for government licensing approval early next year.

Researchers propose new ultrasound screening criteria for diagnosing polycystic kidney disease

Current criteria not sensitive enough for patients with rarer form of the disease

23 oct 2008--Modification of the current screening criteria are needed for diagnosing patients with autosomal dominant polycystic disease (ADPKD), according to a study appearing in the January 2009 issue of the Journal of the American Society Nephrology (JASN). The results suggest that some patients with a milder form of the disease may otherwise be misdiagnosed.
ADPKD, a genetic disorder characterized by the growth of numerous cysts in the kidneys, can lead to reduced kidney function and kidney failure. It is the most common inherited disorder of the kidney, occurring in approximately 1 in 500 births, and symptoms usually develop between the ages of 30 and 40 years.
Individuals at risk for developing ADPKD are commonly screened by imaging techniques such as ultrasound. Diagnosis can also be made with a genetic test that detects mutations in the two genes that cause the disease, called PKD1 and PKD2. However, gene-based diagnosis is expensive and detects definitive mutations in only 41% to 63% of cases. In many clinical settings, it is rarely performed.
Testing for ADPKD in individuals whose families have a history of the disease is important. Young people who know they are affected may be able to better preserve their kidney function through diet, life style modification and blood pressure control. Testing also can be used to determine whether an at-risk individual can safely donate a kidney to a family member with the disease.
Ultrasound screening for ADPKD is based on diagnostic criteria developed to detect cases caused by mutations in the PKD1 gene. This form of the disease is more common and more severe than the form caused by mutations in the PKD2 gene. Therefore, there may be a need for different diagnostic criteria for patients with the milder, less common form of autosomal dominant polycystic disease.
To test whether this is the case, York Pei, MD, of the University of Toronto, in Ontario, Canada, and his colleagues performed kidney ultrasounds and genetic tests on 577 and 371 at-risk individuals from 58 PKD1 and 39 PKD2 families, respectively.
The researchers found that the ultrasound diagnostic criteria currently in use may misdiagnose individuals with mutations in the PKD2 gene. Therefore, the investigators designed new ultrasound criteria that could accurately detect the disease in individuals with mutations in either PKD1 or PKD2 gene. They determined that in families of unknown gene type, the presence of three or more kidney cysts is sufficient for establishing the diagnosis in individuals aged 15 to 39 years, two or more cysts in each kidney is sufficient for individuals aged 40 to 59 years, and four or more cysts in each kidney is required for subjects ≥60 years. Also, fewer than two kidney cysts in at-risk individuals aged ≥40 years is sufficient to exclude the disease. For at-risk individuals aged 30 to 39 years, the absence of any kidney cysts provides almost certainty that the disease is not present.
"For the first time we have derived a set of highly predictive criteria for ultrasound diagnosis of ADPKD that is suitable for test subjects with either gene type," said Pei. "These unified diagnostic criteria will be useful for genetic counseling and for evaluation of at-risk subjects as living-related kidney donors for their affected relatives," he added.

How eating fruit and vegetables can improve cancer patients' response to chemotherapy

UC Riverside study describes how naturally occurring apigenin facilitates the death of cancer cells

RIVERSIDE, Calif., 23 oct 2008 – The leading cause of death in all cancer patients continues to be the resistance of tumor cells to chemotherapy, a form of treatment in which chemicals are used to kill cells.
Now a study by UC Riverside biochemists that focuses on cancer cells reports that ingesting apigenin – a naturally occurring dietary agent found in vegetables and fruit – improves cancer cells' response to chemotherapy.
Xuan Liu, a professor of biochemistry, and Xin Cai, a postdoctoral researcher working in her lab, found that apigenin localizes tumor suppressor p53, a protein, in the cell nucleus – a necessary step for killing the cell that results in some tumor cells responding to chemotherapy.
The study, published this week in the online early edition of the Proceedings of the National Academy of Sciences, provides a novel approach to conquer tumor resistance to chemotherapy, and suggests an avenue for developing safe chemotherapy via naturally occurring agents.
Normally, cells have low levels of p53 diffused in their cytoplasm and nucleus. When DNA in the nucleus is damaged, p53 moves to the nucleus where it activates genes that stop cell growth and cause cell death. In this way, p53 ensures that cells with damaged DNA are killed.
In many cancers, p53 is rendered inactive by a process called cytoplasmic sequestration. Apigenin is able to activate p53 and transport it into the nucleus, resulting in a stop to cell growth and cell death.
"In therapy you want to kill cancer cells," explained Cai, the first author of the research paper. "But to stop cell growth and to kill the cell, p53 first needs to be moved to the cell's nucleus to function. Apigenin is very effective in localizing p53 this way."
Apigenin is mainly found in fruit (including apples, cherries, grapes), vegetables (including parsley, artichoke, basil, celery), nuts and plant-derived beverages (including tea and wine). It has been shown by researchers to have growth inhibitory properties in several cancer lines, including breast, colon, skin, thyroid and leukemia cells. It has also been shown to inhibit pancreatic cancer cell proliferation.
"Our study advocates the inclusion of vegetables and fruit in our daily diet to help prevent cancer," said Liu, the research paper's coauthor.
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The National Institutes of Health supported the five-year study.

Researchers examine evolution of genes that trigger the body's immune response to viral infection

RICHMOND, Va., 23 oct 2008– Virginia Commonwealth University Institute of Molecular Medicine researchers have traced the evolutionary origin of two genes that serve as primary cellular sensors of infection with RNA viruses, such as influenza, poliovirus, West Nile virus, and HIV, which may ultimately provide researchers with insight into a possible new pathway for the development of innate immunity.
Recent studies by other investigators have provided information on exactly how humans respond to virus infection and the role of innate immunity in protection from viral pathogenesis. Induction of innate immunity is closely associated with the production of type I interferons. Interferons are a class of proteins that are secreted by the body in response to a viral infection such as rhinovirus, the cause of the common cold.
In the study, published online in the Early Edition of the Proceedings of the National Academy of Sciences the week of October 20-24, the VCU team reported that melanoma differentiation associated gene-5 (MDA-5) and retinoic acid inducible gene-I (RIG-I) originated specifically in mammals. These genes induce the production of type I interferons.
"Understanding how these unique genes developed and evolved provides a unique opportunity to understand the origins of innate immunity and to develop ways of exploiting this process to develop new types of therapies for pathogenic viruses," said lead investigator Paul B. Fisher, M.Ph., Ph.D., professor and chair of the Department of Human and Molecular Genetics and director of the VCU Institute of Molecular Medicine in the VCU School of Medicine.
According to Fisher, MDA-5, but not RIG-I, orthologs are found in fish, indicating that MDA-5 might have evolved before RIG-I. The unique domain arrangement of MDA-5 and RIG-I evolved independently by domain grafting and not by a simple gene-duplication event of the entire four-domain arrangement. This process may have been initiated by differential sensitivity of these proteins to viral infection.
"Our studies provide insights into the shuffling of gene regions, which culminated in a unique mechanism for protection against viral infection. Additionally, our phylogenetic analyses of these domains provides one of the first direct insights into the temporal pathways of development of innate immunity," said Fisher.
According to Fisher, expression of both MDA-5 and RIG-I can limit viral replication post-entry in cells. In this context, identifying drugs that can effectively turn on either or both of these genes offers promise for decreasing virus-induced pathogenesis.
In related work, the team has identified the promoter region, which controls expression of MDA-5 and RIG-I. Studies are now under way at the VCU Institute of Molecular Medicine and the Burnham Institute for Medical Research in La Jolla, Calif., to use these promoters as part of a screening paradigm to identify small molecules that can be developed into drugs to treat infectious diseases.
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This work was supported by grants from the National Institutes of Health.

US suicide rate increasing

Largest increase seen in middle-aged white women

23 oct 2008--The rate of suicide in the United States is increasing for the first time in a decade, according to a new report from the Johns Hopkins Bloomberg School of Public Health's Center for Injury Research and Policy. The increase in the overall suicide rate between 1999 and 2005 was due primarily to an increase in suicides among whites aged 40-64, with white middle-aged women experiencing the largest annual increase. Whereas the overall suicide rate rose 0.7 percent during this time period, the rate among middle-aged white men rose 2.7 percent annually and 3.9 percent among middle-aged women. By contrast, suicide in blacks decreased significantly over the study's time period, and remained stable among Asian and Native Americans. The results are published online at the website of the American Journal of Preventive Medicine and will be published in the December print edition of the journal.
The researchers also conducted a detailed analysis of suicide methods across specific population groups. While firearms remain the predominant method, the rate of firearm suicides decreased during the study period. Suicide by hanging or suffocation increased markedly with a 6.3 percent annual increase among men, and a 2.3 percent annual increase among women. Hanging/suffocation accounted for 22 percent of all suicides by 2005, surpassing poisoning at 18 percent.
"The results underscore a change in the epidemiology of suicide, with middle-aged whites emerging as a new high-risk group," said study co-author Susan P. Baker, MPH, a professor with the Bloomberg School's Center for Injury Research and Policy. "Historically, suicide prevention programs have focused on groups considered to be at highest risk—teens and young adults of both genders as well as elderly white men. This research tells us we need to refocus our resources to develop prevention programs for men and women in their middle years."
Baker along with colleagues Guoqing Hu, PhD, Holly Wilcox, PhD, Lawrence Wissow, MD, MPH, analyzed data from the Web-based Injury Statistics Query and Reporting System (WISQARS) mortality reports, which provides data on deaths according to cause and intent of injury by age, race, gender and state. WISQARS mortality data are based on annual data files of the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC).
The reasons for the increase in the suicide rate are not fully understood. "While it would be straightforward to attribute the results to a rise in so-called mid-life crises, recent studies find that middle age is mostly a time of relative security and emotional wellbeing," said Baker. "Further research is warranted to explore societal changes that may be disproportionably affecting the middle-aged in this country."
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The research was funded by the Center for Injury Research and Policy.
Addition media contact: Alicia Samuels, MPH, Johns Hopkins Center for Injury Research and Policy, 410-614-5555 or alsamuel@jhsph.edu.
For public health news throughout the day, visit www.jhsph.edu/publichealthnews.

'Western' diet increases heart attack risk globally

American Heart Association rapid access journal report

22 oct 2008--The typical Western diet — fried foods, salty snacks and meat — accounts for about 30 percent of heart attack risk across the world, according to a study of dietary patterns in 52 countries reported in Circulation: Journal of the American Heart Association.
Researchers identified three dietary patterns in the world:
Oriental: higher intake of tofu, soy and other sauces;
Prudent: higher intake of fruits and vegetables; and
Western: higher intake of fried foods, salty snacks, eggs and meat.
The Prudent diet was associated with a lower heart attack risk than the Oriental, researchers said.
"The objective of this study was to understand the modifiable risk factors of heart attacks at a global level," said Salim Yusuf, D.Phil., the study's senior author.
Previous studies have reached similar conclusions about the Prudent and Western diet in the United States and Europe. This study broadens those findings and identifies a unique dietary pattern that researchers labeled "Oriental" (because of a higher content of food items typical of an Oriental diet.) The dietary pattern recommended by the American Heart Association is similar to the Prudent diet described in this study.
"This study indicates that the same relationships that are observed in Western countries exist in different regions of the world," said Yusuf, professor of medicine at McMaster University and director of the Population Health Research Institute at Hamilton Health Sciences in Ontario, Canada.
Researchers analyzed the INTERHEART study, which documents the association of various risk factors and the risk of heart attack in about 16,000 participants in 52 countries. Here, they analyzed 5,761 heart attack cases and compared them to 10,646 people without known heart disease (controls).
The researchers created a dietary risk score questionnaire for heart attacks patients, based on 19 food groups and adjusted it for dietary preferences for each country. Trained medical personnel interviewed the heart attack patients and the control group. The questionnaires included healthy food items (such as fruits and vegetables) and unhealthy food items (such as fried foods and salty snacks).
"A simple dietary score, which included both good and bad foods with the higher score indicating a worse diet, showed that 30 percent of the risk of heart disease in a population could be related to poor diet," said Romania Iqbal, Ph.D., lead author of the study.
After adjusting for known risk factors, researchers found:
People who consumed the Prudent diet of more fruits and vegetables had a 30 percent lower risk of heart attack compared to people who ate little or no fruits and vegetables.
People who consumed the Western diet had a 35 percent greater risk of having a heart attack compared to people who consumed little or no fried foods and meat.
The Oriental pattern showed no relationship with heart attack risk.
Researchers said that while some components of the Oriental pattern may be protective, others such as the higher sodium content of soy sauces, may increase cardiovascular risk, neutralizing any relationship.
It's expensive and time-consuming to establish a large and long-term study examining the relationship of diet and heart attack in every region of the world. So the approach of this study is the only feasible way to examine the relationship to diet and heart disease from multiple populations in a relatively short time at an affordable cost, Yusuf said.
Data from this study helped confirm that changes in dietary intake, including the consumption of more fruits and vegetables, can help reduce the risk of having a heart attack in populations worldwide, he said.
"At the same time, an unhealthy dietary intake, assessed by a simple dietary risk score, accounts for nearly one-third of the world population's attributable risk," Yusuf said.
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Other co-authors are: Sonia Anand, M.D.; Stephanie Ounpuu, Ph.D.; Shofiqul Islam, M.Sc.; Xiaohe Zhang, M.Sc.; Sumathy Rangarajan, M.Sc.; Jephat Chifamba, MD.; Ali Al-Hinai, M.D.; and Matyas Keltai. Individual author disclosures can be found on the manuscript.
The INTERHEART study was funded by the Canadian Institutes of Health Research; the Heart and Stroke Foundation of Ontario; the International Clinical Epidemiology Network; and through unrestricted grants from several pharmaceutical companies (with major contributions from Astra Zeneca, Novartis, Hoechst Marion Roussel [now Aventis], Knoll Pharmaceuticals [now Abbott], Bristol-Myers Squibb and Sanofi-Sythelabo); and by various national bodies and pharmaceutical firms in different countries. In the United States, King Pharma provided funding. A complete list of funding agencies are in the manuscript.

Depression, health care services and heart attacks -- what's the connection?

New data points to psychosocial factors impacting how often cardiac patients seek further care

22 oct 2008--Depression symptoms are associated with significantly higher use of healthcare services following a heart attack, according to a new study released today by the Centre for Addiction and Mental Health (CAMH). With approximately 70,000 Canadians experiencing a heart attack each year, this new data may help thousands of people get the care they need and reduce hospital visits.
"While we know that the use of health services is higher for people with depression symptoms, and depression is common for people who have had a heart attack, this is one of the first studies to quantify the relationship between depression symptoms, cardiac illness severity and their effect on health service consumption," explains Dr. Paul Kurdyak, head of CAMH's Centralized Assessment, Triage and Support research program and principal investigator for this research.
Data from almost 2000 heart attack patients showed that depression symptoms alone resulted in an increase in health service consumption with a:
Nine per cent increase in heart-related hospitalizations,
24 per cent increase in total re-hospitalization days, and
43 per cent increase in non-heart related hospitalizations visits following discharge after a heart attack.
Surprisingly, the data also showed that depression caused the greatest increase in health service use in those patients with lower cardiac illness severity, and therefore, the least need for those services. "What we're seeing is people who are clearly in distress seeking help from our healthcare system, but it may not include the right kind of help to address their distress," says Dr. Kurdyak.
While there are well-established and effective chronic cardiac care and depression intervention programs, "this data supports the need for integrating depression screening and case-management into existing cardiac care," says Dr. Kurdyak. "Integrated depression care for people who have had a heart attack can improve their quality of life and may reduce the apparent mismatch between need and service use."
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To arrange interviews please contact Michael Torres, Media Relations, CAMH at (416) 595-6015.
The Centre for Addiction and Mental Health (CAMH) is Canada's largest mental health and addiction teaching hospital, as well as one of the world's leading research centres in the area of addiction and mental health. CAMH combines clinical care, research, education, policy development and health promotion to transform the lives of people affected by mental health and addiction issues.
CAMH is fully affiliated with the University of Toronto, and is a Pan American Health Organization/World Health Organization Collaborating Centre.

Respiratory rhythms can help predict insomnia

22 oct 2008--The breathing and heart rates and cortisol levels of women with metastatic breast cancer can be used to predict if they'll suffer from chronic insomnia and sleep disruptions, a common complaint from patients who want to maintain their quality of life, according to a study by scientists at the University of Rochester Medical Center.
This report, published in the Journal of Clinical Sleep Medicine, is the first to identify the body's parasympathetic nervous system, a branch of the autonomic nervous system that controls breathing and heart rates and the body's response to stress, as a contributor to poor sleep, which is a persistent problem for women with breast cancer, according to lead author Oxana Palesh, Ph.D., research assistant professor at Rochester's James P. Wilmot Cancer Center.
"We were able to identify the role that the parasympathetic nervous system plays in insomnia. It's reasonable to suggest that simple breathing exercises may help more than we realize with insomnia," Palesh said. She is a member of the University of Rochester Cancer Center Community Clinical Oncology Research Base, which specializes in cancer control studies.
She suggests regulating deep diaphragmatic breathing through yoga, meditation and other techniques may help thwart insomnia and sleep disruptions, which are two to three times as common in cancer patients compared to general population. Scientists don't know why people with cancer experience greater sleep problems and how to prevent it. Many doctors prescribe people with cancer various sleep aides or hypnotics.
Palesh led a study of 99 women with metastatic breast cancer or recurrent disease over 45 living in San Francisco. Among the women, 39 took antidepressants and 19 used medications to treat their insomnia
Participants collected saliva for cortisol measurement for two days, completed questionnaires and wore actigraphs to monitor sleep and awake cycles for three days. They also participated in Trier Social Stress Tasks, a standardized social and cognitive stress test, after their cortisol baseline collections.
Scientists measured participants' heart rate during a stress task and found that lowered heart rate variability was associated with efficiency of their sleep, how long after sleeping that they awoke, how long they were awake and the average number of times they woke in the night.
Results showed that most women spent about eight hours in bed at night, but had on average 15 wake episodes in the night with each episode lasting about 5 minutes, for a total of 71 minutes
Insomnia and sleep problems are tied to fatigue, mood disorders and sometimes psychiatric illness, and can reduce quality of life for people facing the disease.
In healthy people, cortisol levels peak during the morning and typically level out during the end of the day. However in more than a third of the women with metastatic breast cancer, circadian rhythms are disrupted and cortisol peak multiple times or rise during the end of the day. In this study, Palesh found that Cortisol disruption was also associated with waking up at night.
In studies of healthy people, evidence shows people with insomnia typically have an elevated response to stress, which contributes to the problem.
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Palesh completed the study with former Stanford University colleague David Spiegel, M.D., who is known for his research on support groups and cancer patients. It was funded by the National Cancer Institute.

Chest scans may help monitor spread of head and neck cancer in high-risk patients

22 oct 2008--Among high-risk patients with head and neck cancer, chest computed tomography (CT) may help detect disease progression involving the lungs, according to a report in the October issue of Archives of Otolaryngology–Head & Neck Surgery, one of the JAMA/Archives journals.
Developing a second, distant cancer (a metastasis or a new primary cancer) is an important factor affecting survival of patients with head and neck squamous cell carcinoma, which accounts for most head and neck cancers, according to background information in the article. The most common site at which such patients develop new metastases is the lungs, with an incidence of 8 percent to 15 percent. Chest X-rays are the most commonly used screening tool for detecting these malignancies but do not always identify early abnormalities.
Yen-Bin Hsu, M.D., of Taipei Veterans General Hospital, Taiwan, and colleagues evaluated 270 screening chest CT scans performed over 42 months in 192 patients with head and neck squamous cell carcinoma. The scans were categorized as new cases, follow-up cases or recurrent cases, and results classified as normal or abnormal.
Of the 270 scans, 79 (29.3 percent) were considered abnormal, including 54 (20 percent) that identified a malignant neoplasm of the lung and 25 (9.3 percent) showing indeterminate abnormalities. "The rate of an abnormal scan was significantly higher in the follow-up case group (44.2 percent) than in the new case group (14.2 percent)," the authors write. Patients whose cancer was classified as stage N2 or N3 (indicating some degree of lymph node involvement), who had stage IV disease (in which the cancer has spread to another organ), who had recurrent disease or who had a distant metastasis in another site were more likely to have a malignant neoplasm of the lung.
"Indeterminate lesions were common on chest CT in our study, and special attention should be paid to them," the authors write. "Based on the progressive changes in follow-up scans, 44 percent of indeterminate lesions were eventually considered a malignant neoplasm of the lung. We also found that small (less than 1 centimeter) solitary nodules, which were usually resectable [operable], carried significantly higher chances (66.7 percent) of being a malignant neoplasm."
"For patients with head and neck squamous cell carcinoma, chest diagnosis is crucial and may influence their treatment plan," they continue. "In conclusion, chest CT is recommended for high-risk patients, especially every six months for the first two years during the follow-up period, although its role is controversial for patients newly diagnosed as having head and neck squamous cell carcinoma. High-risk patients include those with N2 or N3 disease, stage IV disease or locoregional recurrence. For patients with indeterminate small (less than 1 centimeter) solitary pulmonary nodules, aggressive evaluation and management are imperative because of the high rate of a malignant neoplasm of the lung."
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(Arch Otolaryngol Head Neck Surg. 2008;134[10]:1050-1054. Available pre-embargo to the media at www.jamamedia.org.)